On the Brink of Survival
Mani S. Kavuru recounts how a 40-year-old severe asthma patient in a full-blown exacerbation quickly escalated from dangerous to life-threatening
When a severe asthma patient is in a full-blown exacerbation, the situation can quickly escalate from dangerous to life-threatening. A 40-year-old man with a 30-year history of asthma typically only used his nebulizer once or twice a week, but fall allergy season was beginning, and he began to administer it six or eight times in one day. A few nights later, the patient awoke at 2 a.m. feeling as if he couldn't breathe. He had already used his nebulizer three times that evening and agreed to let his wife drive him to the emergency room. When they arrived, he was barely able to say his name and ask for a nebulizer. The nurse took his vital signs and triaged him to a more aggressive part of the ER. There, a resident assessed him, ordered albuterol and intravenous corticosteroids, and asked the nursing staff to start an IV and put him on oxygen. He ordered some labs and asked for a blood gas to be drawn. Once the respiratory therapist administered a nebulizer treatment, the patient began to look more comfortable. "(But) you could still hear the wheezing even without putting your stethoscope on his chest," said Mani S. Kavuru, MD, director of the division of pulmonary and critical care medicine at Jefferson University Hospitals, Philadelphia, as he described one of the most difficult cases he had ever tackled. A RT recommended switching the patient to a continuous nebulizer.
After two hours in the ER, the patient was admitted to the hospital floor for observation. As the resident wrote up the case notes and orders, a nurse ran out of the patient's room saying the patient was obtunded and not awake. The clinical team made several attempts to acutely intubate the patient for transport to the intensive care unit, but the patient had a difficult airway. A senior anesthesia fellow was called to perform the procedure. The fellow administered narcotics and benzodiazepines to aid in intubation, and the patient was transferred to the ICU.
In the ICU, a nurse noticed the patient's blood pressure had dropped to 70/40, his heart rate to 130, and his face and chest were swollen. When she palpated the patient's face, arms, and chest, she noticed a crunchiness under his skin suggestive of a pneumothorax and air leak. A chest X-ray revealed a bilateral pneumothorax, and a thoracic surgeon was called to insert chest tubes bilaterally that released a large gush of air. But the patient began overbreathing the ventilator, so the RTs unhooked him and began to manually bag him. Eventually, they administered neuromuscular blockers to sedate and paralyze him. A chest X-ray the next day showed that his lungs were fully inflated.
The RT department continued to monitor the patient's ventilator pressure and settings over the next few days, and began to withhold paralytics so the patient could wake up. By day five, the patient was still unresponsive, and the clinical team began to discuss possible brain damage; however, a CT scan, MRI, and neurology consult revealed no problems in the patient's brain.
Two weeks later as the clinical team began debating whether to do a tracheostomy of the patient or a trial of extubation, the patient started becoming more responsive. He could follow basic commands although his extremities remained weak. He was extubated and transferred out of the ICU with the anticipation of a slow recovery and rehabilitation.